...

Student Code 16JMNC2701YI

by user

on
Category: Documents
78

views

Report

Comments

Transcript

Student Code 16JMNC2701YI
Student Profile
Student Code: 16JMNC2701YI
Last Name:
Aoki
First Name:
Nozomi
Middle Name:
Gender:
Female
Date Of Birth:
01/31/2001
Age On Arrival: 15
Birth Place City:
Setagaya-ku
Birth Country:
Japan
Citizenship:
Passport #:
MU4375677
Expiration Date: 01/15/2021
Kagoshima
Country:
Japan
[email protected]
Postal Code:
891-0141
Native Language: Japanese
Address:
2-702-27-406,Taniyamachuo City:
Telephone:
81 992665290
Email:
Japan
Grade level (US): 10 th
Program and school information
Is this an IEP (Intensive English Program)
Yes
student?
SLEP (score):
TOEFL (score):
ELTIS (score):
Are you currently studying English in
your home High School?
Yes
Have you taken any Private English
Lessons?
Yes
How many years have you studied
English?
4 years
213
Have you participated in any High School
No
program in U.S. before?
Have you officially graduated from a High
No
School?
What other foreign languages have you
studied and how long?
Language 1:
Language 2:
Language 3:
Years:
Years:
Years:
CHI will consider requests from students who want to attend private school at a cost. Please indicate if you want to be considered for
a private school and pay tuition.
Please note: Select carefully. If you check “Yes”, your choice will be considered final. If you are placed in a private school, you will then be
expected to follow through with attending the private school and paying for all costs.
Private school selected option:
No
Your family
Relation
Father
Mother
Brother
Name
Koichi Aoki
Akiko Aoki
Go Aoki
Age
44
43
13
Page 1 of 27 (Student Code 16JMNC2701YI)
Occupation
Management
Employee
Student
Living with the Student
Yes
Yes
Yes
Your Health
Are you allergic to animals?
No allergy
Do you have any other allergies?
No
if yes, explain.
Are you presently under a doctor's care?
No
if yes, explain.
Do you presently take any medication?
No
if yes, explain.
Any medical reason or circumstances why you cannot live with
pets?
No
if yes, explain.
Do you wear glasses or contact lenses?
Yes
Are you vegetarian?
No
If yes, do you eat anything besides vegetables (i.e. fish, eggs)?
Are there any foods that you cannot eat for health or religious
reasons?
No
Do you smoke?
No
Do you understand that smoking is illegal and not allowed on the Yes
CHI program?
Will you be willing to live with a smoking family?
No
Your Preferences
What is your religion?
Not Religious
How often do you attend religious services?
Never
Will you be willing to attend religious services with your Host Family?
Yes
Will you be willing to accept double placement with another exchange
student?
No
Will you be willing to live with a host family with young children?
Yes
If no, explain.
About Yourself
List 3 things you are currently most involved in:
Tennis
Traveling
Watching movies
How many hours per day do you spend studying?
3 hour(s)
Which are your favourite subjects at school?
English, History, Math
What time do you go to bed? school nights
Do you understand that you must follow your host family's
curfew and bedtime?
Page 2 of 27 (Student Code 16JMNC2701YI)
11pm
Yes
what time do you go to bed?
weekends
11pm
What qualities do you value most in people?
I like those who have cheerful characters and
never speaks ill of others.
How big is your community?
Town
Have you ever worked?
No
If yes, please explain.
Why do you want to spend a year abroad?
I would like to be more independent.
What will you do to help make your year successful?
I'll talk with many people in English without
being afraid of making mistakes.
What are your future occupational and/or career goals?
I want to be an interpreter.
How do you think your exchange experience will help you in the I think I'll have more choices for my future
career.
future?
Have you been away from your family for more than a few days? Yes
If yes, indicate for how long and how it affected you
What can you tell us about yourself, your personality or your
habits that will help us match you with a host family ?
Page 3 of 27 (Student Code 16JMNC2701YI)
I stayed with a host family in America for one
month. I was interested in English and I could
find my dream.
I'm very active and I love talking with my
friends. I'm also good at playing tennis.
About your family
Describe your relationship with your parents and siblings:
We are very close and we help each other.
What does your family enjoy doing together?
We enjoy playing tennis and always go to hot spring baths together.
What are your family rules?
We make a point of having dinner together.
What responsibilities do you do to help your parents at home?
I hang the laundry to dry and clean my room.
How do your parents feel about you spending a year abroad? Do they support your decision?
They understand and support my decision. They hope that I will get a great communication skill,
knowledge about history and culture of America, and many other things through this experience.
Who should we contact in case of emergency other than your parents?
Name:
Chinatsu Dogo
Phone Number:
81 90-8886-0143
Relationship:
aunt
About your host country
What Do you expect from your Host Family?
I want to have a good time with my host family everyday with full of smiles.
What do you expect from the students in your host school?
I would like my American classmates to know the differences on the culture from America and Japan.
What do you think you will miss most during your exchange year?
I will miss my family the most during my exchange year.
Do you understand that if you contact your family and friends often, you will not adjust to American life? Yes
How do you think you will react if you get homesick?
I will ask my AC for advice and I will make an effort to get over it.
Check off the adjectives which best describes you
Active, Ambitious, Athletic, Competitive, Curious, Family Oriented, Gentle, Honest, Humorous, Independent,
Intellectual, Open Minded, Optimistic, Organized, Outgoing, Talktive, Thoughful, Tolerant, Truthful,
Check off the adjectives which best describes your family's lifestyle
Academic, Active, Affectionate, Casual, Independent, International, Modern, Sophisticated,
Student's interests
Interests and Hobbies
Cooking, Computers, Hiking/Camping, Movie/Theater, Reading, Traveling,
Sports in which you participate
Golf, Roller Skating, Swimming, Tennis, Track and Field,
Musical Intruments which you play
Guitar, Piano, Recorder, Singing,
Other hobbies, sports or instruments comments
Additional comments for PDF Application
Page 4 of 27 (Student Code 16JMNC2701YI)
Student's letter to Host Family
Dear Host Family
My name is Nozomi Aoki.Please call me Non. Thank you very much for accepting me. I would like to introduce myself. I was born
in Tokyo and moved to Kagoshima when I was two months old. It is the 10th largest prefecture in Japan. It comprises two major
peninsulas, Satsuma and Osumi, as well as many small islands such as Tanegashima, Yakushima and Amami Oshima. There are
many places to visit in Kagoshima. Kagoshima is nice place to live and full of nature.
I have a cheerful personality and I’m a hard worker. I have been keeping a positive attitude towards everything in my life. Also, I’m
very active. I have two hobbies, doing exercise and listening to music. Especially, I like doing exercise very much because it is
good for my health and when I do exercise, I feel comfortable. I like tennis the best of all sports. I play the tennis since I was a 7th
grader. I was able to win the tennis match five times when I was an 8th grader. I’m good at hitting the ball forehand. I think I’m the
best player in the class of tennis school. I’m interested in shopping and watching movies. I often go shopping and watch movies
with my friends on Sundays. I like foreign movies. Recently I watched Harry potter, Big Hero 6, Monsters Inc and so on. I would like
to be able to watch movies in English without subtitles someday.
There are four people in my family. My family members are my father, mother, younger brother and myself. My father is a principal
of some nursery schools. He works very hard. Thanks to that, I can go to school and live happily. I always feel grateful to him. My
mothers hobby is cooking. The dishes she cooks are very delicious and she is careful about my nutrition. I want to be able to cook
like my mother. I respect her very much. My brother is a junior high school student. He goes to school called La Salle. It is the
smartest school in Kagoshima. So, he is very smart. I have a black rabbit as a pet. I named it Rokku. She is very cute because she
is small enough to rest the palm of my hand. So, there are five people in my family. My family is very close.
I go to junior high school called Shigakukan. This school is very popular in Kagoshima because I can enter the high school without
taking entrance examination. I get up at 6 every morning. I go to school by train. When I arrive at the school, I play tennis with my
friends for half an hour. The first period starts from quarter to nine. I can learn various things in classes. At noon I have lunch with
my classmates. Everyone’s lunch box looks very delicious. After the lunch, I talk with my friends during the noon recess. Then we
clean our classroom. The afternoon classes start from twenty to 2 p.m. I practice tennis for one hour from 4 p.m. after school. I
come home at 6 p.m. I enjoy school life every day.
I study at least for 3 hours a day. At first I do my homework, review lessons of the day. If there are any problems that I don’t
understand, I ask my teacher or my friends the next day. I study English hardest of all subjects. I study English in three ways. I
make it a rule to study English for one hour each day. I listen to English for 30 minutes a day. I learn 20 English words in a day. I
will continue studying English and improve my English skills more.
My dream is to be an interpreter. Of course, it is important to speak English fluently, but also I think it is important to learn the
cultures and customs of various countries. So, I would like to participate in this program. I think I will learn the differences between
Japanese and American culture and life style. I can become more independent. I like to communicate with many people and I
would like to make a lot of American friends. I would like to go study abroad to make my dream come true. I’m looking forward to
seeing you all soon.
Sincerely Yours,
Nozomi Aoki
Page 5 of 27 (Student Code 16JMNC2701YI)
Parent's letter to Host Family
Dear Host Family,
We are parents of Nozomi; Koichi, the father, and Akiko, the mother. First of all, we would like to thank you for hosting Nozomi. We
are very grateful for your generous offer. We would like to introduce our daughter, Nozomi.
Nozomi is a positive and hardworking girl. She works very hard both on study and sports. Because of her positive nature, she has
many friends at school and always smiles and laughs with them at school. She plays a leader role at her class and is known as a
most reliable girl among her friends. When her class had exhibition for school cultural festival this year, Nozomi prepared most of it
as a team leader helping organize the class. Ice cream party after the festival with friends has become one of her memorable time.
Nozomi started to practice tennis since she entered junior high school. She practices every day by her self other than regular
practices at school. She started to play at private advanced tennis team to improve her skill. Now, she is a main player at her
school tennis team and also enjoys playing with boys in a varsity team of the private school. Her younger brother, Go, also started
playing tennis this year because of Nozomi. They like to chat and play tennis and table tennis together when we go for traveling.
They are like best friends together.
She was born with hardworking nature; she has been trying her very best with study, sports and every other field in which she was
interested. She has visited America for few times with short homestay programs. She found her dream to become an interpreter
when she turned 15years old and told us that she would go to America again and study for one year. We were very proud of her
searching the way to achieve her goal by her self and works harder than ever in order to make it realize. Since she applied to this
program, she has been studying a lot to improve her English everyday until late at night. She made the first place in her grade at
last exam. Nozomi has a strong will and toughness to do her best in everything. We are very proud of her.
We have to mention how she is helpful around the house. She helps the mother with cleaning up after dinner, doing laundry and
ironing. When the parents are not at home for work, Nozomi cleans up the house and prepares meals for her brother. She let us
know things happened while we are out and that how the brother has been doing. On weekends, we enjoy going for shopping, hot
spring together. She let us hear her daily life she spends with her friends. When she needs help, she is very open to share her
stories with us.
We can easily imagine that she tries her best in America as well and she will have a wonderful year with her host family and people
she will meet. We believe her school life in America will be fruitful filled with smiles on her face as well as people around her. She is
looking forward to meeting her family in America. We hope that you will share a wonderful year with Nozomi. Thank you in
advance.
Sincerely,
Koichi and Akiko Aoki
Page 6 of 27 (Student Code 16JMNC2701YI)
Naぃ o JApJta虻
ハ″
'動
魚 め長 i
″ ′
●はwheapF y ic wH s● lctい )
コ、
e abovo sⅢ dent【 s arP'ng Fe,Ⅲ o Acttqln o YearPttB an ⅢⅢ CHI ttmeng mmJ s価 ●
いose who haVe wod EnJtⅢ sに コヽ ncx t hty e ld o ttコ JiⅢ 〔
oっ 迎■●pate D 3● u、 前 ぶchコ 18c PIoSiam wiuithbr h。 、価■ ト
hふ he● ec込 ヽo匹 c● F∞ 1。 W』 dfrcAnct
overcome b“ 】 ■ es chess● lectc oncs hav.go前
suド ● of hHmor anO b● お 1● O inoセ ,こ EW iiCnこ tab● litFofい omユ ●nt and
)血 Antivn nⅢ
ule“ uuc対 、 ch伍 JetCr and側 1は blは ,fer an AfFIⅢ v iC YPT A市
CHI wt低
〔 ン側 (o`"dn hmest ophicnす
o■ 〔てヽe fn‐ Dl製 屯 ヽiPn and do(r16n th● bottom m卸
【 ン。u fer your im● 311u● 0刀 sヽ こcLじ 。 A
SCh∞ 1 41Dd● Ornunitv Fげ
,t聴 o卜 │よ (約 tbe
ap■ ude lttt bo u● ctrssA o●
apl的 ,市 ala bex bdN!
E
Roa■ 1■ ,
′
ヽマ市tl□ 宮
レ
S,o■ h■ 資
′
Coコ Preヽ 。■,to□
ヤ
PE韓 い
ulc sⅢ
C
A
F
抑
●xCh
ngc Prusr‐
Scコ 1● :
E‐
Lxcell● nt
C‐ C∞ d
人 一′
ヽ erag●
F‐ Fair
Cibc wtt you ttet htゃ 。11● 伍ェ、
京w d orsho,ld ndい ocヽ osen ror nc Attde「
Ⅲ.RI、
EngllⅢ l的 却 agt aЫ ltues a● 〔11ud●
田 】
ivaio,a“
m“ 市 ,【 ●v● 1晰 Ⅲ ,車 ,,4 tOや よ hg Jld inctsn n■ 14卸
●Du祖
..【
Engllsh onlメ
=。「
ucと ar
Pro2rat loLing iFTc roun【
d dnd stlaay habiは ,caF 001Si雄
ho stt ucnl、
「
environmo“
nラ
タ●r
彰
中
器%
`18naⅢ
N卸 て。r sch。 。1」
Shぃ l
Adur弱
6,多
D並 みァ/′ ″々 クF
ィ
■1筑 ■ /a叫
/
Ⅲ
ク
″
PoHd● ol●
'7ク
l,pい oⅢ o
`タ
た″
Formお
Page 7 of 27 (Student Code 16JMNC2701YI)
/
タ:をどをちご】をどをE2ど を:!二
ととととと″
をを歩
"―
o crII、 r
stuセ 紅
AP,車
rい 0い
申
唖
…
Nmeof的 ,■ ea li
I m d esttacal'sMぉ
よ町
oい 辺 堅堕堕 猛″
ス
ク
″励
汀F響 花売進 r
`じ
,sttue t、 コぃ ,tn3 0「 tl eれ adttllc Yea Progim ttn Cm A皿 加 g ntt slJdents輸 ● app,WC W“ 。ま ●●toサ
llac mo La7● he chere● ●r ntt bⅢ v ana mmmtvloOar t,剖 セ h全 側 II rd ttcht171r,拘 atam Mu ndi 10“ 臣町 1,SC lesl
卸 d comコ 的 ilv Sua matntto b● 的 oい時 ヽ lo■ 41n Oこ huntt proga r hAlshe nerus● nlcept cul価 麹 uirreNncqtl ev●
"ene
価 跡 gi品
m41eabt tc ttHmll口
ho田 es t 61s,r● に rate mhe、 bav● 却 od scttS・ Ofittmor be ablolo m」 cIN henよ
swa ung envお 劇 In虹 に Ch HJttfoFd esヽ u.Ht ctu O“ ぅW.“ kン s b,1,● 町 ⅢO〔 tSt oPItOn ofⅢ oま」den● sい erafrcr and
Su“ Ⅲ h「 加 hatent Y● Iハbre4a挫 岱 e団 ロェ 述 dA● 。n dlAbotton n a k tt f● r your【 br a■ d lonSt● 前 o“
pl.慈
“
Pleaso cheok o9 6o apprspr敵 o bex bo10W!
Mat■ i
RcsPoBg市
IIv t● │●
r
R●sPcE8:blLs
“ t● others
並 alol
XXo□ 苺
E‐ Ewtt et
tlu●lコ 困
Scnso● f■ ■mor
6=6ood
A=A● m餃
Cx46Ⅲ Ⅲ
F‐ 工旬r
PersoBtt mo■ 強 do■
N‐ Netrn。 ,.
Ataa● ttio monla6。 コ
Abdltl(じ adant to□ er ex
,lo■ ●饉
Abutv b htracttttL otloド
OVOr駅 品 4取 Ⅲ r
descr bo輸 yメwf● ●lho却 pに 的 ど卸コuld u shω ld■ o(院 hぃ n fe,」 ●Acaa● o ve釘 ,ぃ″卸、httn=b"olo江 d be
onw O(村 d。 四 ut■ urn●7
d● ntヽ あ町 (,a軽 Ⅲ■ty価 n西前 け 品`udtte mdentb● a poこ rerramtttv● 征 h切証 ●
,1● ase
sn
I「
sに 的 コ
“
tth」 ,
』●■g tth a bollt“
`g“
車
,,い A品
7江
鮎炉
N的 ●oFScHl∞
S● hoo Amぃ
鮒
Sittth r
函
o
三 呈
括
″r
■Ⅲ
Form招
Page 8 of 27 (Student Code 16JMNC2701YI)
1
0 01 AIF Hra Ap X● vl,"1,
(乃
bC即
'7h″
り た と′″ わ
Stltt Fr t744噂 で湖
筋
"rjr a■ "″
″ 御 ″ rr 2r加 2vた
を4“1,olを ″′イビ″ 夕立""で
S StZo″ s,並
Nane oF App陶 ●
店
拠
。。′Sr47T2。 ′∫″ rr″ た り
“
A∂ 片
NuH工 r,rし ● ●i Crao(
oぃ EEwl■ E4toロ
帥
ヽ
的
□ Mac
tt Fenat
i所ヽこ●I● lm,o,Sロ
r“ o
“
“llall
E対 ●
SuDertSr
A crB+ │
B orB I
ヽLり α コd
ユア 一
つ
ハv● ぃ
“
sunctenl
Fa〕
VOr(fO■ Lt)
2つ /3
crau。 1併 el
SubJec`
ヽハ′
4 ′つつ7
7は
コもIIr4H
Earrlts4
0
ド
e,
す
4/
th
げ
●コul
r
‐
S
`
ouWMに どに
“
口
"run`“
る
fj 6
御 さ
′Dヱγイ
S
】
0ぃ 0● P9■t Av● ぃ g●
■胸 Crdお R申 口rrt
■西 1● ● dに Eara● 0
Nロ ェ ber
ofは 的 的 的 ,1,4VI
Aし ,● B【 ど
IB daFS)
勘み
絲
鮮
柴
Ma■
!穴car
b″ 】
Fnrm石
Page 9 of 27 (Student Code 16JMNC2701YI)
ヽ■口●oて 単 `∞ !
0● Ⅲ, ハγ々,述
nl人 ,, 降 Vi立
"13
わ 」″〃と,″ rrヱ
(乃 あタタrre″ 倣 ン
″θθr q海 ご協ル ″″slgrr2″
夕並 わ ″ Prr72● 772″
′″ ″vあ 夕切 ″わoた ″r筋 ,2 2s"″
sc72ο リア帥 sを 沈
ITZ夕 rrrrF2″ ″"4立
Name ofAP,Ioanti Aあ
Crade ExPla■
ヌ∂″
,
ヵ 少た,
Excellellt
A■
5
Supcrlor
A
す
A‐ oI B十
4
G6od
Wを 呼
国
Nlllllber Or Letter Crade
atiOコ
Good
B61B‐
C
Averagc
o炉 でr2パ 秘 θo′ 立″rrlP″ 最 4r″ ″ 脇
Male
)
ご
Fcmalo
,Vords
″
;
SuFncient
C‐
ニ
Poor
D
′
Fail
ク
「
Year(frOmた
0
2ク /゛
SubJect
/2'′ 字
,ο
/2ク /f
″
′
76
Grtlde】 ●
vel
HoH恥 7w● ok
ュク/r
8`h
Cra31
/2ク ′F
94h
Ho■ rsアwelk
G,コ do
Howrs/wl。 【
Crat●
1
Frrg:,s,
と
す
と
す
ち
S
2
協
す
r
す
す
す
々
オ
孝
す
々
て
や
古
“
f
ど
す
ど
す
イ
占
″
す
む
す
字
ヽ
や
す
3
す
す
/
す
/
す
す
/
す
/
イ
す
2
r
′
字
Ⅲで
3
S,● デ
″′セ
効
4
″か材2ヵ左rr
S
Si′ .ヵ 4″
6
月
7
財 ″ゃ ′n
"あ
レ
s
rr
″か ?%[で,ぁ ′ ,あ ,,ぁ
8
打,十
9
q″ ″ルnftと
"
ぁ り,初湖とヵっ
9
2
′、
も
二
V
13
Gradc Polコ tAverag●
々 、
r、 ο
″、8
つうと
ヽ)ア
■もtal CⅢ dits R● qured
Tol■ l credits EarJ●
d
う や2
NHmber of IIstructiollal Days
Abse■ ces(逝 days)
ユ
′
Sig■ attr●
練
コorm 45
Page 10 of 27 (Student Code 16JMNC2701YI)
つ
⑤ CHI AYPSt,d●IltApp Rev 102013
d曲 逝理0
│■ ■
艦言重玉重玉面高正五正五亘百高so an卸 or al1 0は ■
tl●
Nallleざ ApJた
価
:中
Datc ofBirth:立 ゴ
基
一 と
】
海″
"
一
r汗
産笙 ゴ
2生
、
Ⅲry杏 ,
h速 即 。ft
Hlodt対
Stat● Htent
nHst a他 ●l
aに
形″
―
Dヮ
gvc datc(at l統
軌
le follo胡 llg?Pleaゃ oと eは (〕めYestt Nα
,Date
idcd
belぃ
いi■ l he sPace prO■
1llless and detaled infoナ .1.4tlljn tegardmg a ly IElpa―
Do ytlll■ tt or hFt■ e you evげ
醐 Mぷ c慈 蕊
をキ彗置」とと:き告せ;
lls,tre■ 価 ●nt・
o■ SCISitl■ ■hr・ 母 mpl● ■
HleⅢ 胡
19■ S
亜 d ttp● ●にd futtlre treatte■ t
Doン 。unぃ r
α
lla■
。fally Offlle Followlllg?
e you eVCr had anv di団 ,筑 e,mpallFAellt o,お dOra anす
Plttsc chect S3 VCS or No
Abdo述d Orgags,DIgestlvo Sy壁
k
Evesi` dfh4ycPlaj ch● ●
■
ito一 Urularh SIStem■
型 竺
dMお SelsⅢ
Hett cI Bl。 。
B166d,mCemc syStemキ
=
S慮oゎ 16blelllsⅢ 単(r
Bram,NervKluS SyHelll空
岱
TotrSilS,N6so研 Throat
"fOr a■ y Ofaba■ ej Wo ll● ●d th● 0中
la■ atl● ■ S
If“
Y菌
″
fOr ・Ⅲ ,■ 。ed PLysicla■ 'S Statenle■ t is EttgllshⅢ
舘
寵留
昌
IIas Patlcnt e■ α ooralllHod a ly other kFtld oCsPOCIallSt7
gl■
ed改 むls
0 0
El温
爛 帯
総 鞘胡帥edcallonれ 硼 EIIS
酬欝総縫龍器翻す
験:鑑 錯:鮒 鉢描隅缶
rrS tO anj oftlle abい o,p最 ゆ
豫酌
If“ コ
Ⅲ
ul E理 1lsh
atutCt芝 髪生 鯉
コ
叩 dm` 臣
姿一一__Datc璃 宅第一
Sheet oF paper r needed
PlcascdOllotwiteclithcbacltoflhisFoHll.USe an add蛸 。■狐
コ 6m号
Page 11 of 27 (Student Code 16JMNC2701YI)
7
⑤ CHI AYl'StldFlltAtt R●
A10例 i3
rrBIsフ 4野 ″
rル
●り″ 陸
Nttc ofAppuc加
″ rIPr″ ●θげ 加 ″
おフrF42 arr秘 れ あ ′訪 じ、醜
:Nθ Zつ mtt yL笠
__
″
Pr2rsF御 抑
Datc ofBI赴
4r2″ が
″
あ ″S4Z″ 出 芝 幽 り
r
: r/サ 白″っ
i%",
D41
E8Mよ c
ttCmac
ア″
ンなと
P降 淳 卜 みア
Prllvide ngures for the noEKlwIJle:
?占 es BNo rm)「 ette dttbe_
e
狙ellttthg alarts?臼 Yes磁 輸 Iws,JeaSe deserお
PHp皿 叩 証 販 。や0● Xes ttm莉
旋
Does mdellt ha■ e aty sears研
甑041● jH● atlKln ttor甲 orts
Are there tt rettct10ns cl tllc stlldelltts,anclpatltt lll p町
tl●
actt■■
s?□ Y● s
82ね
ヽ
o
Ifyぃ ,please o中 lain
Desenし o h dcta1l eacll dlsease,ltllpalm041げ abnctl■ aiけ t10t
f・ll,ox91atled
ljtl uSIs fom:
IFde student weaFS glttses cr eol・ tact lcnSes,Plette coraplcte The Follolvlng ophttlalmio hfOmatlo■
Vl韻 on宙 mi
知
glttscMenscsi OD
B4Se Cdrve
d
Ot● r
Gl■
e jour cPllHCII1 0ftt gcneFal Statc()fthe candttate's hcaldl【
睦Ex6● lle成
Thc ndcnt mtt P燕
国6ood
日 Far
。わ ate h athl● II郎 :画
EI P00r
Ycs
□ N0
)に
か筋 ″ ′″ガ
″α ″ pr2が たlr伊 ″力θrrrθ ttι α′力柿 θり ザ姥 C'″
r a`脇 才
五 挽 効 姥 rSを確 4″ 御 タゴヤ ″ク r720殉 lrgIPllJsを α
“
"θ
物 筋 θ″な α確 初 ″
a筋
確 /1n協 ″ α″殉 θア惚″ ″材 協
grCゆ
??物
為儀 緒 稔!陥 ほ舌鮒
統
酌 げsioiadヽ Nalne lPleas● サPe Klr prntl
Takaaki KubozonO,
一tr Ptlヵ 句
│
―
ク
?イ
142cマ ″
に
。/Eイ _/2沙 と
S上
ど
盟総
■わ
イ
'あ
口ortH組
Page 12 of 27 (Student Code 16JMNC2701YI)
.れ
ツ
」
イ
/1X j / そ
"
③ CHI ttT Smde■ lApp
R軒
10′
21●
rあ
rTF rsク rrg“ ″″、
韓
l●
Pl″
●ク″′″r42〃 ″″cク rrtr"夕 ″中
“
“
t ttP tant逸
型
hd rと
_巾
此
と
′?″ 2ヽ 7fallA“ ″ゴ堂 望幽
卜
で ″● ″′
“ “ "″
翌
,",
DoT
“'
′ □ ぃ た 脈
嗣 ビ
清″
"し
Provide nttuiss t)l
Are p■ Jlar7
the● loヽ ving!
descibC
Nsば no Dle容 じ
and(■ ee rene、 cs hom』 ?Eltts□
Does ttHdo■ `ュ e any scars or ne止 ぃ ng martS?□ 遮
Are thett any restictisns lln thc sl■ dent's parict,ation tiヽ
lf}●
、Picあ ee` Piain
□
No ryci J・
,ヽ ysiCat
educttioFi
aSC dSsc古 Ⅲじ
anJorspoよ
‐t市 市es?□ 稚ヽ
日 ヽo
_______
Descibe in detal each disettesimpatrme lt or abno■
I,IJ● 章■使 nt、 ヽcTs g'aSS● s ol()01ltact'■
mahけ not偽 1)● Xpta ncこ
nses ploass coⅢ
PI● 1。
o●
lheお lis、 、1,=。 や
!`
3is Fstin:
(■
■lⅢ
i■
t r!"ュ とo■
'●
Cylinder
SPhere
(OD)Ocular Dexter
一き17す D
(OS)OCWiar Si■ istcr
一 !oo
Vision wihout giass●
字クク
Add_ヤ ニ生 ≧ 重 クI二生 」包 分 だ 望 狂 ワ
″
Other
Give your cPl■
1。
Base
D
2θ
s'lenses:OD
Prisll
Axis
み
じ
QS 22/
あ
eCutヽ ユ
グ
'ase
''と
ー
ー
■。rhcと cncmi starc of the calldidatc‐ s hcaithi
□ 駄制にnt
r
□ Fホ r tt P。 。
□ NO
The smdent may parllttpttc h ttmetcH□ 【s
□ Good
なわ,ブ ヴ 7方 でc″ ″ rC
ttca′ 力
″crセ ■をwで ,rカ タ″ι
:ar7 a“ 7″ 筋arわ ″α
夕
″旋ハ′
,力 .r■ egデ l_2″ ar″ θ,つ ■
8h″ りど
irカ ビ″
`″ `力
浄″
クsら 2夕 ″,″ cあ ル″α″′rカ クr′ ″ abο v?セル,,″ αrゎ ″なαてcl1/7rrt9
rllPrDl l17″ r lle力 caん 71r2′ ll arわ ″カ
r1227α ″ブ
CC″
り伊
ll″
″
“
Physに lan` s Namc(pleA● ,Pe o■ print)
劇岱_タ ルお与率多争字
タニゴ6ず 二鍵
Phone numbcI:_ナ
疼物池
_
′
'/=_タ
Ph】 sictan's Signalurei
Foralヤ 8
Page 13 of 27 (Student Code 16JMNC2701YI)
防o
C CHl AYP Stuむ ●1lt
App lく
じ、lⅢ 120 1S
oす
BRh:_立
】
Z"″
/舛 /夕 '今 r暖 14お・
Drp
妨
薔温塩冊 継撚縛 鮒 縛諾翻 麟 縄 紺灘 十
憶 艦 桃瑠 群
轍押
‐
狐
tllCSe
hmぃ
Ⅲ
l叩 Sげ Rllt軌
路
を
縄き
線せ
盤瑠
樹鮒
銘緩錦x,M鼓 島
3豊 総鮨 器
樹紺嫌燃盤 錨 群総紘慧盟
齢品私協精鞘縦納 設
紺品襴 縦亀
tlttSな 0
:こ
Date cach dOse gⅢ ●■
VACCINE cFormatrkLttn/d里 当壁D
DDDTPDTaP(DAPLterね
44 mln品 コmll■ ●last
dP研 苺lsl
r■ L blrtLda■
“
mo紬な切サCar
ぃondlldaVケ 西
POLIO AIYELrrIS
/
st bc arter 4tL brnda■
と
脅,々 ,っ rす
■2m五 血 IEl
IIEPA■ ■■■SB
■3 1113SiEUll
/
7/″ ″ぅ
CEICKEN POX
守mttesl
3/′ ィ ク 老
=2811■ lBIml
/
RUBELLAtcr"M基 応Ⅲ d4y ncasldl
7/277第 2
血
nEENINCXpcOCCAL
/
Ⅲ2nhttHIll
BCC Va● ●lDttm(mmttyeatj
TD S■ lE Test datt lm64bVe0
縦
撒
7/多
/
/
r__Rcsults ttNcgahvc
′ ′
′/
ヽ
夢
/
」
十
/
/
ke l P● A
か Od加 ●制 dlnt tt Cl●
r Aolmnur4Z14弘
′
/ 7
Ifh61E H n密 宜OHヨ Ve t"帥 血
rdれ
ll t由
Mcasは
跡
7 /
6
〃″。
【
fm lrmu・ 14atに 」Ve
du汚
′
"n,s
煎山ell had雨 旋 lla
′
/
ⅢrDneれ 。ρヽarマ
□ Pcs■ 市C
date(総earlど の
クめ
ゴ
(i迎 工
l16▼
1」
血逸 回 堕型 曲
劇 lts from a h韻 的
い e rCCelttd血 劇
慰
/
have bl● 0● ●IIPletedい
う ″ り,│・ 迎 匹 o如 的 直 麺 ロ コ 」 娘 ω 車 亜 四 国 陶 凹 劇 墜 凶 出 鄭
Chest X R4y● Iamhat10■ rePoH― Extthttljn
鐘 態
/ /
l■ Fattm)百 Ⅲ d〕 ●nd● 成 Ed
。。こ rnoI―
フ /
ti強″ イ 協
EIantta統 ■―nlst
S
′多
7/ラ ′
PS
剛
■
2 Hl■ln―
CurFe■ をTB
′
″ゲγり
'
/
'2 HhlBIIBl
Ⅲ2H血
nsnth aッ ケOar
/
す`物
7〃 ?ヵ ′
10と
lle rrtt母 なen「
l
EEPATTHS A
ntEEAttES mttdE‐
m611tWd料ヽ o21
巧16か 塚 匂巧″
!争 ″7チの │
t al■
5th
│
l
監淵路撫品鮒艦樟淵紺拙盤! 物勉グ!;
t4841bttun tTLelastsL●
711 1
。
々ダ
b印 少
密 彰存 可″多
夕イ聯夢牛
,Tetands a■
s■ ot tllttt bo o鈍
3■ d
郷
lst
r
掛
逆出畦 逆四出適
9
:
甘
園 OthCrs
Ifothcls,JCasc c親 血
4擁
、力仰 。さ は ク″わ707g74P夢協
抑稼 夕S辞
∽′
約″脇 す
ヽ
Nan● ole亜 碑α
れ
JD'
ふ恵
'9け
',脚
A品 職S駆
仰
ガθ″2Zrr抑 め
=釘 "″
姥
″族 姥勢 rrlプ 泌″筋 rz″
物げθ
T
aル
タ″秘 セこと 拘 ヮ ヴ 挽
'な ″
〃″
0セ
そ lzF97Mttθ ″な
、え ヵA初 五 々 ″ り、″う
渉
rHげd● xa.tt Sttnaturel
ン 2ヱ 生チ2多 一つ′
Page 14 of 27 (Student Code 16JMNC2701YI)
W血
加仏
rc″
冴 ar7
"協
"ο
r 上
′一′′
八′。ぁん
塑 当 上―あ透
上挫
あ る物 迦 塑 ぬ 座 止
Pllonc nll mberiキ
o弾
Oα 泌
'"竹
る 9ク Fltレ 4勉 ′k亀後 夕後 l・ A駐 を セ 膨 ●
」//〃 r″ 7ク/rみ
/う
Nalhc cfApphcant
Dttc of81Hh:__立
/ラ
協 商
う夕
1/2の サEllvltte 配
十cmょ c
承
形α
Ttt rc寧 ■記 inmunlzatlo■ sm■ st bc takell phorto ne a■ lvtt i正 o he U s TAo dateslMonh/DttNc‐ )。 f irimlmセ 施 ljns α
nhesses h卸 。お bc dcarljr前 tten below,ァ 碇 以 alllh価 oこ doctcI Each Stalc alld sttd llas dttrmtreq岨 ね nellts ra studclll
is,1“ ed in a Sate orsch。 。l that retlures addltOtlal v従 ●
incs,431e s価 能 nt w"!have lo gd extra shttsじ ゃ
fo々 Jle arrtwal in6 the
u s rdlc mdcntlusncth減 はe folbttig iiness苺 ,C htcteal Pは ,Mttles)ヽ ■mps orRubelL alitに so mmulzatolls are
reOdared Studellts sllNld ma【 o。 的】 。
I10rltO cOlll,lctc u16sc retuiゃ nen低 所 or to tho PrOg血 (or preferattγ 晩るre sllbllnほ ing
述 S aD,1と at10nl rdle sIIdellt aH対 es widlsut。 。mpletr略 IIlllnullzttlKlns,ね o口 n】 狙 parcnほ are respo困 ibie FcI却 1● osほ IIlt‐ tllred
Date●ach dosc」 確n
VACCINE(rformat LE/E的
mo lb74av、 述
DT/DTP/DTaP● ⅢLterla,Teta■ lls a■ d
Tdap/dTaP ceta■ us alttd,r● dH● od tlPith● Hat● FOid
&郎 cJdar aCmSSiS f● ■10y● ars c】 do口 oコ 々 1811E血
a■ er■ i
/
77づ1″ク。/
bitLdaぅ
CIECKコ N POX
lo dtt measts)
lHum
mo● 61dar/j ear
ち,″
2り
oz ′
つ/ダ ′
予夕7す
9レ クタ
々ぢ
/
REENINGOCOCCAL
′/〃 ″イ
ン//夕 /夕 ″′
r iolnm tjセ ぶon留 ve
nd価
Cur京 加t TE EInlllidat。
ョ ve
/
/
/
da● 卸 五 m
7
adM● asLs
/
dコ ●卸定● thad
7
/
MwⅢ o
“
rDo hmu_t。 、 か oと ぃ●a■ d● nl
/2ク み
6
//夕 ′
/
/
ア
了fュ oIImHmセ
′
クす/フタタ
=2 all■ lmull
′
g vod“ ●smdetlt htt CluoAe l Pex
ク
ク
る
ク/夕 ′
″
ん
ク/イ タタ
4sLⅢ 3 d4v lnc叔 づ
/
/夕 み
`
RulFLLA(cer nd M・
Ⅲ2almulwll
え│ぢ1のヽ
多
″T
/
夕/′ ″ 2ク ジ
mlusIPs
Ⅲ2価
Hlll
tt RtsA拡
/ 7
/
■― must Lave b`● L● Oalpに tetl■■tLIn the last 3巴 」蟹登
BCC VactlnatoBl onondッ ヶea71_う yと oイ・ IfBCCヽ な
温 6o■ 品 ●コ dl● stX Ravr●
“
TBSttTestdate mω
Ncgttc EIPosmc・
_J__Results:日
Cl● st X R4y elalllla4jb■ relDo驚
■亡stt● ocrttt
露 Rc確 』cd m
園 Ohcrs
mo llW“ wlj oar
IFEOImmЛ ねdcn
夕/′ ″/ク ゥ わ夕身 タタデ
=2前 ■山 Inl
SLESは.bedaヵ
no tlKり lv朝
夕/rタ ク タ ウ々 タ タ 身 ク/夕 6
Ⅲ3BllmlH」 Hl
Bli■
料ヽ 。何
`7,守
′
?″ ヤ
す
″′
HIPATFIS B
■2
5tll
す わ
=2“ 市宜tJ■ 31
い酪
的 嗣
=)■
=48品 血 HIl c■ ●hstSLot mtt b●
H〕 tPATITIS A
″
lta
ち
″客 ′物r7r /努 タイ r争θイ
ィ/タ ッ
″
?″ ?グ す
PFmISSIs)
bi「 thlla)
r4BlxtlHl● ■l lTLo last shot■ lllst be attr 4は
POHO nIYEL口 雄
3■ d
211d
s■ 姓
Ⅱ口st
b●
DF゛ ld』 す
子f rrnミ thLh r、 .qt X Ilav冶 :画 抽 曲 岬 画 廼
F_x8nta■ On date(■ loJldt■ ear)′ ξ4Z″″すk中
dlat tle pttoll nalned above rce胡
い0
、
配 llleお 1lcII■ ng remls ttm a cllest X Ray:
abttlornlalltお s
lfodlcrs,,lCasc cxplah
4″ ●″脇
殉
初
Sを″甥 力御 Cさ い
ぁ
r″ブみ抑″2'b″
a rr・
加
0っ 4ヵ ,7Jslc47 α O務ル″力″″″ っ 酌 褒 ″夕″切確 ″ 力なゎヮ ザ 協夕″ ″力筋 絃 rcク ゥ ぁαr
効
筋 プ励
,peげ prlntj_
Ad古 ●
stt Sa意 出ni【電は駈ma HttP鯛
才
Ph。 ■
●nmaberi+8! 々 2-2タ チ 少′01
Physlclatl's NamelpLas。
Page 15 of 27 (Student Code 16JMNC2701YI)
滅
″擁
旋
Takaam Kub(協
メ
Nよ た
PhlsLian's SIgnatrα
擁
解
櫛
stt rt4ォ
級
朗
滅
″°
T
gク 2-り 9ク を
arr
N“
中
ヽt asP… ltS
●
rsi印 胡 stud“ にdo terけ
Ⅲと
Cfthe
r97,ぃ I A・ に
│
"0'Apphcallr
a旺 は
。
・
it
鞘田:紺告
鮒舗総盤軽盟
器
酬檎欄瑞館翻鑑齢翌 錯器撤灘盟
齢出
IIと
su「 g● sn o「
ヽい,lal
ifttf母
ヽoぃ o● oun,atい 】。X'。 n韓
lllis mmo“ zatbn sral bc valid f●
r
j●
dua“ on of me Ctt pr。
│い tire
牟
St Sture cF,Ient
de tiS Partt【 patlng
b西f:
拘
"l
す
防け転 ■
辞
Sig alre OF,arent
IAgcC S gn4HrcOFSH I● nt!_Aち み
s
//ア /,り ′
=ren in whch tho sⅢ
A。
マ イ ワ ′ ク。′す
,dle
11
′ り,イ
″
ン切
"力 “
e.s
打
中
キ
縦
品幡
将
総艦淵温 機縦給献格稗辞
蛸途灘丹
ギ
鮭対針
独鮮 掛盤
m
艦号
冊 蹴温
掛
縄t鷲逮mt告
甘
設絆
鷲3糾 謎富
鴛
a∼景
3路盤路紺獣高
人
●
益 C00rdid●r jvaに 叫
i:告
en t adNaに
1
esentA6Veギ
iぜ
前
s鯛鮒鮮
鹸
lnre、
n泌
S田
ЫttaHre rP観
2乏
」
_Ⅲ
生
陸
玄
盤塑___
_一
上
___ D…
“
1短 ree
Ы抑 加 正
OrSttdenti
″
需
D競
フ ″じ4
? / '
ツ呼 〔
■ 赫
れ 【「
紡 ″り
D血 需宅傘ダ
す
,コ b[lcatlo■ R● 1-。 ●AlltLd― t16■
Igに
,● nH
ss価
rCHlい
お
い
もob7da夢
phoⅢ
ヒf
6 Prdlno(osヽ 配O lt郎 ホalgo on tk,CHI Neb sit
=r8PhS of叫
atons
andltt Cm publモ ●
地 。m円 す P瑚 シ
S gna旺
_Z色透生王塗之二
ば瑚
I Asr● ● ‐ S FD西 ■ 1●
●F
4箸 4詠査
形告
Datei
Srdden,
ユ 0
r所 ,
卓
ンィ
々 /タ
lytei
内じ1)
Ⅲヵ
7V,2
タ
Da ci
′
Pmで ratt DBratoE
切
"′
"句
ar Prpgm n tsln■ hates noぃ ore tha■ ono
IVe,本 Parent rdl● undertlped sh正 、 undusta ld tra【 1に Ao施 ont Y●
r at16o皿 卸抑 切`
sth001 6r tarHer tFrequぃ fFd"r` Nヤ Fa niぃ o「 nt●dedけ i述 ,。
w● Lk hJ er lg hechsurc。 ●
Sws‐
P征 並
“
抑
ahI●
"F血
_立
ね
物
_逐
拠
Zと
立
透
塗
生
___
,),(
:
Dctei
埜
D使
___どととJと
I Asfrt Ste a「 JI・ 。rsⅢ 6● ■t:__」 と」空空 ど
F4111■ 10
Page 16 of 27 (Student Code 16JMNC2701YI)
Dat●
o● m
Bタ
M聯 ヤ
十
"′
転竹
nⅢ
sコ
mⅢ
P
ψ 。13
…
Na【 ne ofAF,liCa lti
rvθ zθ ttF
れ r,
S● lN
areい o CHIミ 宅 ulatons br』 にヽdents Plcase re4d oarehily and s即 】oHr namo
l ■ ●possosson PH【 h亜 o「 Hse oFi1lesal dm宮 o isp"rubSted
2 Studenほ ⅢⅢst ab:d● Ⅲ th。 laws oftbe h。 車●m。 │■
s Sludents drs,olal ow迎 lo PosttSヽ P"● has● or dlink a coい 。Ⅲc beverag苺
4 Stude ts的 に も。│,l owsd“ pH「 chast possess 。lsい 。ol却 ilS Oran】 守ぃ
s
Studonts are nel,onnitedい
dr、● oぃ y【 ェol。「 vehcre
whi e puiol,dttngモ ェthtt Cm P「 ogranl
l Students mは 〔コotpart Patein an】 、本Ha oonは o(or soxml activi● 2 hath nゃ prⅢ Ⅲale
4り rrrrra胡 あ″″ r/rr″ 筋 に ιrrr76′ り
“
″ rrr“ チ才,■ 4
, 3,la■ students arc nd pe
ゆ ″″rrt価o加′を お 材 ss″ !ヵO″ め夕97ぃ 暗 、
rrⅢ ″
″′セヵ
"rr″
:"
“
的 lo l)ltduse tobacco,的 duりヽ Sぃ de
lls are noi allowtu t6引 .。 卜
f hi he host rarn“ y
holne wiulout,emSsoれ
“
SAldenS must aい w4本 be ttbre oFthe'resPonHl)111,as l】 ●hコ ige stutoコs and nake n del● 価 古ぃ0● IF64 0 reFrestrヽ
thei coun,in a poslrivo ma lne■
Snldo■ はhlHsl f91 ow Nhool mlos li的
なsohos dal卜 c。 ■pl● le all、 ホool asstrtments must Pふ s ali Ciassts ttd
n atleasta C No「 ngo
io Sttenヽ mN sp●ak断 81ヽ h un】 oた n Winは h・ 、 sc itheirown com■ 予
n Studentt arc no(Pem“ によい P』打cⅢ 口に nsゆ diVins hm=宅 nd.巨 bungeejHm,ぃ g Parao的 Ⅲ Ⅲ
コmp ng orany。 (hor
ma【 ■西
activill● sd● ●
moと dttng●
Ю us b】
cHI
E Sヽ 市ebⅢ are DOl pe it〔 ed(o viす t tsuch ,laCes tt p。
i3
∞ mogaFhi WebSci
Stten、 shoH10 1硫 ■mttll13 brm“ ba』 Phoこ EcJヽ
1、
1。
。graPhic shoFS adutt theaに 、
ostaSl` `nen、 。r
uld.P釘 ●
nヽ ald inms ald wllbennl..五 lyに S"nSbに
f6rSⅢ h cats lt sthe mdent、 res,ons baを け ゅ makeSuⅢ amヽ J s are pattい ofsr●
calls sh。 ■3 6o blled的 ‖ て
or mddo wih a preFata nに matioぃ 。は lng oa u
】
ari ltilli【
1●
即 ng thc PrOgam lntmajoこ aI
“nu ber of● m西 1(onlnHntajon ls thetr parttts a ld mmts lntemot accc、
Studoこ は sh。 ■ld thSt古 ●
is at Fhe
discrer oH sftheヽ ぃ(hni】 (Soo,“ so17 Fohヽ 1)
li sHmedは mぃ 体 hOⅢ Ⅲ wo“ 品 r thei boH Fa ldies attd att tt a m● mb● I sflhe FalliⅢ by f61 owins fa t,rutt Ald
“
的lunt加 :y hJPing with iniけ o稿 1● S
I Stteatt mu“ mtdヽ cws thar tts、 ゎmiけ ヽPi Vate arsus with oders
IT Snldent canHα ohang● いost hr111モ os and“ hoo s at wi川
加 StudOぉ t are nsI Pttmittd i。 取 。。lHPsけ hmsよ ⅢS A lr p with the hぶ t Fa llj)a tthOol=r● J)o「 ahV価 0「 at4Hi
Perten ts剖 1。 wed iFp● IⅢ Isston f riい o nalurd Pa,nS iS Shrnited beFe∼ hand
】
,Sttdenls ttIRt s 16w resped fo all C,HI Ⅲp● sen alivos and f● l ow iher instt.“ 〔
ons
,o Stude lls are not al ow“ dto mよ olre are市 宮dectsions、 ■Hc Par tillaling ln dl● Ctt p的
ヒヽ
ゎos bedy
=rmisnCh本
pけ 。u St oI揮紅ng n_ed
J sha.lls aroゎ olalowld b wort、 hilt FTtiCip“ ng nthe C,■ ,regl■ m
Fat=“確 わ 〔B芝¢
り ″ rFr。 うクッタ,。書
■
め西 ″″ 々 rrrr rrr rrrFTarヵ れタスIP
"1●
,rrarrrもsd抽 加 れo CPrr″ ″
ク抑 加 節 ″セ
r"刀 ″あ ヵヴ r71タ エア亨よ4
″ rI。
rat「
rr
"″
“
r●
7"Z↓ 抑I
oF tludcn“
Aoそ
防 Ⅲ
? /,/2,な
:
a“
S13naは、oFP3 ntand7or C B di皿
Signtu● 。f Parettt ardle1 6uardiani
酎g
何 ″2ray
あo″ ″ ョ″転 4商
wEほ 07● ″ 2″ 的 1減,″ ″24rrSra″ ″
″ みな 〃
ノ が ,`″ あ
`“
"H確 '″
“ "匂
'は虚 乃 ″ Pr々r4加 切 ″FrrF4拘 あ r22"あ りに
す″ ″筋 西 ″ CFrS夕 輌 ぁ
軌 ι貶 ″あ 昭 竹
S卸 を価
a""加 ″
_
au● 。f be sondng ttencV:__
",
ね セ湖
十
″繁 ン ″
″ 桟│ど
′
0,/
■ゥ
7 /P/う o/ぐ
Darc!
:
ア よ7′
晦
!
Dalf:_Z立 地 生 埜 す
琉
擁
OC■ 1却,Sur● A,p ttv O,013
Page 17 of 27 (Student Code 16JMNC2701YI)
ヽt un往本筋 db● feloWing
Vク 2′
′
NJ■ o olA,Pllo』 i!
l All oF CHI AYP hostttmllos art■ olunte本
2 ,に
査守 o b re■ lbHぃ o ule hos、
faml転 he SCR● ol or C口
│く
"' Aレ
飾 any exloこ ses)ヽ deFhene
ィ
chltes or d unages he
snldent caぃ 。s
3 Us●
Priv〔
of corr puに も odi p「 onesい o6怖 pS
1●
J苺●尽 。ra叫 。lher
eに ctronに
d"te`ap古 もにgeぃ 。〔と
ght ifthヽ
go ls abtted (■ ●●
oは oHu● nce ma】 b。 (ernponI】 ●oniscaton dr loss ofrig ltto uso ule devic.
“
4 C町 oannul gヽ ちrttt00
gに duat。 ュ 。、
■hd dⅢ lotna or gradc Placmentleve An o、 ■Pt O■
retardS tO grate plarenentic■ ei fs,sⅢ d● nts I● qutring Co〕 vatida(bn
WH
使 ぃato wth
s
rhe stud。 ぃ、ls resPo,si6 oい rけ モ
ng ng Ⅲ the u S arIohc atia■ sけ て
,tolⅢ ●MOST
RE● Arr=浄 des Mnslated
6
AHaコ ロnge nen、 おr oblaithg tta l【 ■,● dlld ha dに Re CCI Valita古 on oFsohool woよ nre sttd● ぃts And nahnl
p西 ■Dは Pα ttnat resPoコ sibHiけ `1い 。■
rranglme lts Fsr ConN41【 daton【 ndst bo l。「SOnal y conIPに tea bン Lhe
sludent beFoⅢ leNing並 【
サS o「 oD Oな 3(:onatに o wlllじ ocharged CW isnol【 ●。
●oompl● 1loぃ of
「」、
POnSbl● 市
tanstt pls er 6nvo1 3alion ho「 ts CHl● さ
o■
し
に
fdl
mail
Dg。
cesls本
ciatqd
will
Co5v,h
daむ
的
on
。
「
N4H「 前 ,aren` 6心 Jtts other ret,ives md titnd。 ぃay no(vヽ t hesnd●ntattng tl..xoha把 〔pr6gram CM
las f6und hatふ its iom hon■ cα ぃぃ 。anSC Nrsndy d`mpl【 v● b ulo adJusmentPrdCttS uStS mus(laに
into EttF l軌
7
ptl● ot the coDCluSお n of he PIo=rm V Sttsisstttd 14k●
h● 苺 ヽ mi,lo,ゆ
Vモ
`■41SO undertlmと
dosccemmodttbns Oい
rSSo〔 vallods
or visis AIo dD'aHOW・ dコ
at a bd hoて o16thcr hm o、 FE“ lng he
an eln● rgoHげ
shu市
じⅢ
dlat the student is not aい 。
wed te r● ⅢⅢ Ⅲ hヽ あ●
rヽ oぃ o的 unヒ 】du ns tho prosは
8
At Chrishl苺
9
Shodd ule sttdent do llbP加 】seD。 」S uhess,hdunngtl.lin、
1lmo(D● o印 ■ berlい olヽ (FTlげ 1け
。 Fthe
stl denlls to spend ul。
A"闘
、he
win higherに
m
llt ramll,
i aLA,Pc oFs前 oHs ttthg 6sorder or
scrious psyth。 loと モ
oal disd der whilo Pttc P“ ng in the Cm proglモrn lhe md● lt wlll be d stthnsod io血
tO his/her home co血 け hnmediコ にb at hiSher ohvn spense
10 SⅢ dent・ InJst h"。 enmBh tanttatt Sk前 卜(o in前 ぃⅢ an a ld lt htlio● in tho 4m・ ヽcttl hish、
AT ald
wllt r笥 ■
m
い
。。1】す。
ぃ
軸●●OSSfall,
1l lfsfudell S atntted Frem a high sohool、 h‖ ●。■lhe CHIprsgmm d● sludent Mu beropnthH● d back Ⅲ Ⅲヽあer
home。 印加中 4nd hiSho「 v sa wtHヽ e re■ to』
hns sn undisclosod P∼ 々xisthg nl● dicat ol,wcho103【 041 00 1dition or he sⅢ dtntis uk ng any
undsdosed medctt on、 CW hド he ttght Ⅲ ■sぃ 忘 │い o前遠entttn he AYP,ro野 m slter gettng an
本苺
l tem A10制 ,い ぃ o14h anJOrぃ ぃ lolog st CM htt the tghtts lnr 4 ule sn4」 ●●た0■ NIP眼 め、and
`sme■
sh denls市 使 蕊 psnstい にfer nl cosヽ hvoⅢ 田
13 Ahletr ellgib111り 。r Ftttipa6oュ hoい or oH配 。
旺 lu ar苺 市vitt ar● not ttaranteed
12 1fheH■ dent
1を
i4NVe血
4 1emore ogⅢ ,that wo AaH ral PIenは
nd sNdAntsl diSCtosed a“
ediぃ ,PhFtmaCeultat and
“
,WOい010な iOai inf6mlat on
15 コⅢ nれ はl fu li,tsrespms lに
1)riぃ
ung血 !the sは dtnthas
ln odd tm古 o● ts n3即 a allec oす oblaining a bm■
pr● ferab:oい ぃo a tObit OI oredittar4
suractent mmey tta tajle lumtt he Wara l
ac● ou lt and host lnd1 11ぃ aI。
■ot Po i“ 。
1 lo● oも 1印 Itis
Tい o sclldhg attEcv stnfF has血 :ly oゃ lallled伍 o
above ageobeJls IV● LAV`よ ほOr● ad al d fDllv
HEderStadd(bos● ruLsof CMヽ AcatsE iC Yttr,的 gram and igr● e to abido町 thebl
Sヽ 8■
awe tts、 コ●
“
智
t●
A,た
N0227jl′
)
,
。n.1
“
Si即 4hェ orPtlrcDl anJば GuBIui3■
Sietlatt rt ormrcnl an血「 価 加
S ttaturc erhe send lltFASen叫
9 /3 /ル r
n五 Ⅲl,/D。 ア ヽ
ぃ
怨
Dati
i
D止
tan!
Do●
:
な
枠
主 多
″
必
│ヤ
F。
Page 18 of 27 (Student Code 16JMNC2701YI)
…
,12
―
0011村
“
″ ′ F‐
“ udlntべ
,ヽ
rF` い 弾 01'
N‐ e
〃ゥ,"l rl。 た
oFAP,1に コ■
I
W● g alt Cmtw41 HOm● 車げ htematoぃ o(CF11)“ s cmPl。 メ●
。S Acadenit Coo由 41atsrs he edicl o■ al instmょ on
wheF the shaaltis tts印 o4and he rttstド nm“ ンor fNl diS Win whom the sl血 ert mal ive hそ に)at(heir 4● cis on
and if h● edet althe cost eFde stl de lt or his/her PaⅢ ■
、。r egn s lardtans h easo ol軒 ptnses N、rn。 的 verage of he
ヽ
ぃ Iコぃ。●pci【 け 。。vtrint the stadcnlは じPower ts Pl“ ●lbe Ыndent h a heゃ モ
均lor na■ y oberinsliⅢ tion ttr my,P●
ofo、 :立口 or meatat d。 。ぃr fer hi切 〔r tr●atmcnt
“
W● g anl C配 )its emP19j tt Acadml● C。 げ
■●
st
印
Fa liけ
m、
he educatlen』 inshttion、 heTo lに
st■
dont sぃ signed and lい ●
.orへ
gal
」●
lvo,a11■ ecessコ ,PemitttOns io actヽ nは o,II● nttす
esPec any n tters的 。 ぃ whttltr medifB!or sul r n。 ludin=こ e poss■ H5。 f ttHniSSiO`
。
「転mtlos w h whom thesttdcnt`市mⅢ
ardians"h any stu“
。こ
for"rgicaJ o,oraltOns or any other treattho● (d∝ m●
`necesso,
hVe auul"2。 cHI:、 clnP,9y∞ s Acatem o Coordinaい 、 the educatな onal tt st ulお n whllto hoも tudoぃ ェヽ本stsdod ahd
tho Ho“ Faniけ sr FhmJに wih、ヽom ule studentlr aA nve O"tum he srudent"the∞ 岬 け sfoig ntt hesl」 tentヽ
00St研 4a10f ule lo宮 al al ard七 狙S or PaFlnに lf nesess与 lo sub【 ■■ 【
■edical teaunent ir th、 i.dcemed llecessar2
heお
mentお
r∞
SA●
●
1時
to住
nsdlarion
wm
medta
ttmmrmes、
た。
。面血 nat at ho lt ofttsningい ヽ
け
Ⅲ
l●
4ooomelt he shdert e可 り s g6。 d healuL ul証 姉 動 。r modo』 に COrd hdudtt h ho sⅢ dAnt aP,HcanoH is的
ComJtt anathょ h。 価 entヽ ntぃ 。ぃ ag● h莉 叫 Httsicl sFOt acdvけ
We sra i cHI ls匂 ぃ,も】●os A胡 ●mt Coordinaい ぃ tho edu● abena insumion wh● Ⅲ he sIId“ A(`
いo
mstF皿 ↓y
or fan ites w 41、Ⅲoni
heれ deれ m伊 ⅢⅢ
●価
d
aS点 留 o4aぃ と
thb=pl・
,emtss on to oot o■ otr behalf h o■ ャ
hhs o
POSSIblC represensttOnじ ●bre dle locdl authorllios
rnis authsEZatttn s a11に vttIId ttr u●
的 め ,1● t
A7,Z「
Sittntt re of Student
duratio■ ofth● Cm DroBrm n WhiCh ihe shttentls Parlに
"│
■りたィ
Dalo
Paling
9 /4 /2●
n■ ″お′
′
S
吻
"′
Signabre ofttnt加』dr
D症
Gヱ 配 iani_
:
十
"セ
D競 、
S tnamE of Farentand/er Cuar iani_
Ⅲ
″
““
S夢 oい ofhe Send ug Agenけ
r●
Dot●
:
/ク
:
(虹跡
Host imllyl
あり ′ 】
り
'
/会
,/りr;
′
】
り
"′
D封●
!
Aヤ ふ
ヒネ
イ
吻
"′
FOrEI'13
Page 19 of 27 (Student Code 16JMNC2701YI)
O CHI AV)ヽ
udeぃ て
大,,電 〕 12。 lS
N□■●ofAFPhOant
D● ■ Stt dent and Pa e lts,
7ゥ
殉i Aυ に
1
"″
Par e paliltg■
lh。 人 caと │コ lo Vcar Pmttrar is m a嶺 、■hde F61る oth sttde■ls and parentt No mat“
howに uch y● u
ed nrra d b and,上 的 rd r6r dlt txo a ge ttP守 た ュ唖 ゥboh stud● 、ほ Ftnd Parch`win却 Ⅲ 的 u」 l aPe市 oと of
adaplanon mt adlHⅢ ■eni Maby sは 古↓1ヽ 的 frerを 切 n cuiture shotk wben tnⅢ nISt ttve in th首 「 host o側 ⅢⅢ Illり
mal hN● ●Xpe。 ャ■1。 に about hoJ thh苺 亜●uld be dat arc unrealishc Beは wン Ou wlヽ Snd s,al gies to hcl,yoJ dea
have l。 は
w d oulll■ re shook
oJhat lonc,、 。atじ d or hsmへ k ttd ucPresSed wh:に goD!て臨 口g l thc adJusuntrnt pttcess
Sttd如
i●
`mttanftci
so■oい ot are pょ oF he,,ledi adlustmert串 〔o Atulesコ n.“ me naⅢ rnl,伽れヽ mゲ 能 lh● ploss
Hlese are
ernoi伽
(o assist thetr s。
封 Fげ n reso中 ul:bose issⅢ s P loゃ boさ Nured ulal cコ 」wH be heIPing}o■「 child th「 。ugh th。
adJWSmen eッ oに"1帆
and you can be oFgr● Rt assislance toメ Ourchmd mu ts cHiby disc、 ss ns art3■ 軒 chB Ⅲ abdebv h●
おHo】 ing
l
NTEIt「 4rltjTHAL CaII卜 I AND ESIAIL CHIに nOIs hat stte■ s
and th● tr,arent W Sh to be tⅢ
oolnlnuntaton wtul sAe SdOdla Hじ H● vキ t60 much contct oan hinttr adlHtthelt Cm undcrstulds hat duringい o
ir“ w● .k yoじ wdld whtⅢ c。 ― LAtaeヽ th you,scnね o,か に
r i c4StOb● ol Ⅲoこ nes Cm woud alPttv。 い`
●ommndittten danng碇 4trst w悲 」o、 〔ve■ ■om the ttco ld w● ●k on、草 郎 〔tha【 〕ou and you(soWdo」
limt(
tausn tu no more han N011に ヽOS O● rい Onth W uleobnmicatiol so e容 1ly a■ ala1le we tぃ 。w hal t =lter
sdifncuI
mm o。 価 血 cathg bui ntt docadcs ofhone“ Ⅲ 瑛 Per enCe w。 臨 oJ hat hryou「 cヽ luぃ atlust he′ Sh●
OCCdS tD ntgraに intt and 6ond IIn tl1lⅢ slねmi】 ぃ m,1● 】 ヽ L alさ 。 ast ulatyou discuss hヽ 口。liげ widl your child s
frlendsな nt other relatl■ es and杏 (ther tol m“ PhOne caⅢ s “ttWor■ nall n he nbov。 さ
oh●dul● Pに oso undcrs And r atif
CHI Feot thatyouぃ。Wdaぃ tertt nd ndJH“ ng duoい nc∼aing o31 pho■ oaぃ Ol re ma“ oommunifa“ o● No wlllmi
thosc Neruco oFcsnlmぃ た新 on le bo(clsurc hat wursc Vdttghtcr w31 be abL 16 adjust o thar ht mtttⅢ PIngra n
oo―
口
Is Ⅲ Ash
2
Vお IIS‐ Nardlal parent、 sib inss oth● r ⅢiaⅢ Ⅲs and衛 ondsコ● no(3 10Wed lc visi ult stl」 d.ll durl=dle
はnange Proga■ II has ttund thtt v stt「 ●n home can心 ●●
xtに nd】 d` nouve〔 。thc ad u“ コentPrSCess We ask
hat aiッ v strs occw al th●
hetr chiJd mlof be,的
●
onolusioR
3fthe P「
ogr‐ When fanliけ memb。 ヽms2 wish io● om● いヽo血 Anebca slgn
、shsull 16よ e reNrvaい oぃ s al
eranl a ld tra● I h tho hぃ 【
●
ountt beFsre retuming holne V siぃ
slooAl hetel rahtt than exttting ule hostれ nl,(prnvid●
home∞ unrts durhs ulj Pttgrtt aF■ e■ Ms ts arc aHo、
sい den9
3
HcoommoCatons SⅢ
■dモ Ⅲ
ar ernettcnCI SiⅢ`l31iOい
ls are
no1 4110Wed(o
ctF m tC
Od,t●
い。S,【 r41lZa“
oぃ hOi「
oith●
COUNSEIINC■もu
nav● oeitt a Phone cal er■ Hau nesM野 キ
n which)our scWdmJtNr aSpearsい be
ond upset hい ヽ cas Pに セ
時 advis● 】o,「 soEldttghi可 海 sPttk widl he hos(Ia llモ lL Cm∞ 。dinabr or
Aoado前 oY● ar Adm価 statoL Ctt H■ 臣ヽ使 h● to prsh泊 ●。。unttrng側 ,P血 o assヽ t veur"Dれ aい す drmgh the
adJusu le tprt● ess Pに astr d6 not cttt ul● hosi Caコ I scい ool or eoordhattt d:Ice■ IW.ast thatyew。 。n14“ the se■ 3ng
“
agedり `
直rin yow.。 mⅢ
dtslressoと
4
TO■虹
IIVIAIERSION me CFtIハ ヽ?s toま gn● 01o gⅢ じymrsor.r aushttr rに 中Po的狙う
寸 tO
SIu】
imme「 se in
thoに os(ooコ nけ mmJ。 範dl価 即処 e ll` a nttla tendenり fer stddents to wtt le m∝ tand sロョk with Ctllers iom【 い
●
same cu l‐ EE30r Who sPcat he sFtm● ian却 宅 o口 ●as● ●nooHng● yow sowdauJ● rto immettetヽ 1,け a,Pttachin“
(bls sxptten∝ 宙b ano,en ttd tten【 !け BHSⅢ do Poた o,alioぃ os― untat on a wlllh卸 ぺ 101d吼 and asmit wl
ensur● su● ooss
Tho seコ d:Lg ageコ
lL● se
げ
│は ThIIS Futt exPlat■ Ca tl e abぃ で agrcemo■
rules oF CJ〔 's A4dealに
IAtte Si印 師ュ● 市 Stud●
FI
Vear,れ gr資 旺 a□ a
1豆
HVe LANS akO r● Hd aコ dh[Ⅲ
ngree l.ュ hd● 町 lb・ 回
‖,2,っ l ヵじ1
D.c
? / ,/ぁ /す
Fa■
D定
Signれ 、 げ ,… II■
十
団gnd urt OrParch
SignttE・
thC SCnding人
Da●
“
Ferm,14
0● 印
'"′
FFl
稼字タ
│
m。
nCVi
Page 20 of 27 (Student Code 16JMNC2701YI)
工LdeA4■ コd
ト
″
● 4'
“
ギ紳
Aγ Pヽ 町苺 rt
A"Rev取 加 ●
0,EN[N`,00R“
・
rO T口 〔WOnt,“
iltて
11,601
CULTURAL I10M ESTAY lNTERNA110NA■
―
――
― ― ―
―
1は B口
Jヽ は 的
●lrヽ ヽ●E,s、 R、 ヽ1
F「
=ヽ
11邸 ナし,0代 OAD
―_
- ―
S苺ヽハざ●HJ加 〕 CA“ 毎●1ョ コ
・
_ __ __
【
ふ
AcadcIBlc Year P,ogra■ l
]re‐■roIInent IEP A2reeanent
DeaI Ag● ,cン
For a mecess仙 価d blHoiぐ
:紅 Atad● 血 c Yearぶ chango PttpHL Cne oF Ctt s nnah Piojtles
なfel hc students wal■ jng saぉ けand ab■ 1「voと Nea的 。
cesshl relhて
Ⅲ Wih n● iぃ 。st
Fa ndy CH acrsoma sch。 胡 snd ool mtuL● r Sndcn、 wh hat ttmel「 "苅
41●4 h ulcls,
pr6g_。 ntt gets,政 旋 d!o ul・ r IEP llost Fan1ly ttd hめ ●dlffculies ttndttg mul ici
AW Hosヽ FaE IV rd atlleH闘 綱 y is ml hesAEl● T06・ sIPPOi mden、 h heir
adlusm。 証 Dr_ess lve st●
Fellぃ 市コ〔 TemS
tS aglee n de
“
ng tne student and hts/1er damlal FICDヽ
ald Cond市"tull
価 soFplcwm pttiゃ よお正
bcrlloen c■ ldr』 Hmぃ 町
SbdoB【 五 (b。 lEP A■ T P rogrtt五
Ag● ●ttlent
manomtt and ttt Naturtt Parelは orい o
1〕 に
【wil bale no oon藤 l Wilhコ ンIEPHost tt nⅢ l■mH■ 7 1St
2 1wl■ la■ e re cent家 Ⅲ wia1lw lcP dttSE atOS唖 Ⅲl Jalll田 ,lH
3 111 have a lJ Ssuoぃ vh myh● st Fa llJェ sulo● l ttr or attend、 すIwnt hk l.m local
coerdlllaler a ld dr hoま Fa lu!ン bJbr●
りlm● ●lSC
4 1,■ 1島 low oH ule的 16 ald Ⅲg■ aい 。“
ns oithe prneran】 o■ 立 Esandl wilⅢ 並 hb
b● .dⅢ ∞ no■ rm slatF
S I Ⅲ dcIHttd■ ar muel c町 Ⅲ即 1減 。ns I劇 こ,ol allowodい move tem my AYP
Plaoeゆ nt航 晦 1■ ンISP H6st輸 1ly
6 1mu苺 と、■PrlCI SP'nd llem mン APA a131o。 対∞ordlt a1 1あ りを I n ake cohセ●t
"“
wlth mv駈 並 rIEP host億 血 y alFld IEP● は 卸 ュ苺
7 1fl m ranelpれ h抗 人YP ttcesshぃ and havc PII● IPettNim:I om bave
1
lmodphoE.。 r emlllaccess widl nv IEI Hosl輸 ty
and ol困 smatぃ
8 1、■ 1航talt hゃ 、●■iSr輸 lL tt EP Host iぶly
続
叩 pr6郎 亜 ド haS bees N的 ぃsnJIs H",隆 d
91口
お1
86 1dj ver bOま
iO■●absA●
o bend wth tt AYP■
制●
s tt Al hed`
cre〔 Ⅲn
We
6も ヽ F銅
Hd亜 と呼
ave r●
印 srr
2 tr,内 た (F“Ⅲ
Str dent
●dle CIlrs Tems&cttd tons abo的
H6hle tAttmelt
ras Fr● ●
Nam P●II江 、
s gnatjtreと
Studt l.s Sbalrer
毎 的 。y Repヽ 団勢 ヽ匝
″あ
ハbzθ ヵ
l
価
む ∞
ltle a並
叩
A,た
hg郎 。し函
ぁ τ″
′よ″
!_
2Prr
Palhelpat(I萌 th
sミ1
算
′
す
? /″ 4/ク 少
daU H/V叫
)
Datei
Yと _shmtNmo IV″
Ferm材 ケ
Page 21 of 27 (Student Code 16JMNC2701YI)
S
DHle輪
Ⅲ 唖 五印
CHI Stud価 ●●れ,迎 理 ι塑 里
shl rSr
o NaFF
1
N如 ● 初 旺 こレ J】コを
∼即
聴
hegr― Aa■ jjjslraHN
お七2,ヵ !
ald
Natu nl Parents N8o●
a ld er EP classII ats旺 何
iン
of CFI Aondcn■ c
aner hは ,lst
卵 ィ
的
/仏 と
H l(W〕 コ
1〕
“□ │
コ
,08M l
刊 賦 WS
ELTiS獄
出amB
柵
/4ク
kf
1縛 襴
唯 斎 f掲斜 結 掛 棋 端 艦
村
'2r9770,
Ace
31rth D8te
T3St
Date
Oender
i
N31'Ve(Flrstl La■
0 /3/ 1ら
イ
CiassrSFa88
C8田 ■
lry Or O■ gin
じuage
________ェ
、
READ THE STUDENT DlRに CT10NS 3H THE BACX BEFORE COMPLF「 lNS THlS ANSWEtt SttE武
1)PENED
NEVER ERASE ON THlS AttSWER SHEE■ TEST lS iNVALID,F ANSWER SHEETIS PRE・
4
LiSTENlNG
SAMPLE8 ①
③
0
0 ◎ ◎ ⑤
O
⑥ O ⑥ ⑥
①
④ ① O ①
﹁ 2 3 4
SAMPLEA
SAMPLEA
①
①
④
①
O‐
⑥
⑥
e
す ①
考 ①
す O
オ ①
(0
躙
率
13
14
15
16
17
◎
O
O
布
◎
⑤
①
①
①
①
①
④
O
O◎
⑥
⑥
O◎
e◎
O◎
O
O
⑥
⑥
O◎
200③
O◎
19 ①
⑤
220◎
23 ①
オ
①
25 ⑤
⑤
O◎
260⑥
⑥
O
◎
⑤
③
0
◎
◎
●
21 ①
◎
◎
◎
◎
◎
◎
◎
◎
◎
◎
◎
◎
O
◎
◎
⑥
⑤
◎
◎
O
⑥
e
③
O
◎
0
〇
◎
◎
STANDARD SCOnES
the nじ 前 er correは IH o3●
l sediOn ReOord the"umじ
oヤ
H口 m受
鷲 i今
Page 22 of 27 (Student Code 16JMNC2701YI)
Te∞ rvort
Raw Soofasゃ Sta ndard Scores)rettrto mo ELTSu
Exarntners Manua Ro● ord mo Stardard S∞ es n tho bexas b● !o正
Numはガ Corer bO esbdew
カ
O◎
O◎
8① O◎
9① ⑤
to ① O◎
Ⅲ O
③
RAW SCORES
∞ rod in tho“
⑥
⑥
⑥
③
4①
17 0 ⑥
18 0 ⑥ O
1900◎
お
④ ③ O
21 ① O
◎
22 ① O(9
23 ① ⑥ e
2400◎
Couは
③
①
10⑥
2① o◎
S ① ⑤ O
60◎
⑥
7① ◎ O
S ④ 0 0
9 ① O◎
40 ① ⑤ 0
+O
⑤ ◎
Ⅲ
20③
◎
H3
14
15
16
-7
READ,NG
酷 :ろ 9
S盟 押】ン
紺
1鞘 押夕、 隠
河
タ
海 抑 肥 ″紗/″
渡
Tヽ 11
o■ │● oo「 t
Y■ ヽ
0 ヤo「
1●
unl● ●● olヽ trw,● ●
航
先
劇1 1ountri● ● sIIH
=「
●│●
│
●n“ o「 o● 」
Ⅲ
nPAN
中 ,4,"_
林挙
〔h
日U43756'7
PASS,ORT
AO(I
―
―
―0そ 011エ
円
"ギ ‖l"謝 4:‐
91 ・ │
‐
JA歓 肝
芦
―
15
…
15
締
ふ輸
月■
,日
‐
」A田 201`
r,A‐ ―
」Aは 2021
“
―
t●
品
A● ●
―
―
“
々木 力共
11.―
Pて J,jtA6k Iく て日6■ 6ロ エく(て くてくてくて
てててくててく(く ててくて(く (((
ltU45756775 JP801 0151 0F2191152(て くてててててく(((て く08
Page 23 of 27 (Student Code 16JMNC2701YI)
Student’s Photo Album - (two recent pictures of the student with his whole family)
Close to each picture we have a brief explanation of the picture.
This photo was taken when I went to the history
museum with my family. I learned many things.
This photo was taken when I visited Kumamoto on the
family trip.
Page 24 of 27 (Student Code 16JMNC2701YI)
Student’s Photo Album - (two recent pictures of the student with his friends)
Close to each picture we have a brief explanation of the picture.
This photo was taken when I participated in a homestay
in America when I was in 8th grade. I am pictured at left
in the photo.
This photo was taken when I visited an Inari shrine in
Kyoto on a school trip. I am pictured at right in the photo.
Page 25 of 27 (Student Code 16JMNC2701YI)
Student’s Photo Album - (two recent pictures with student's interests)
Close to each picture we have a brief explanation of the picture.
This photo was taken when I played tennis in
Yamanashi on the trip.
I went camping when I participated in a homestay in
America. I had a wonderful time.
Page 26 of 27 (Student Code 16JMNC2701YI)
∼ 1 . 1 一 ′ I I 一 わ ー ∼ 一 ′ − い ∼ ● わ ー 1 ︳ − − ● I I 1 ■ − − 、 ● − 1 へ 、 ● ・ J − 1 一 一 − ・ ● 一
﹂−■﹂.ヽ㌧﹂い≠ノ∴・、.
Page 27 of 27 (Student Code 16JMNC2701YI)
Fly UP